1910: Early PEP and Insentive Spirometers

Cohen's Resistance Valve (Figure 38)

Physicians near the middle  of the 19th century were aware of the importance of exercising your respiratory muscles to prevent and treat lung disease.  By 1910 the concept of taking deep breaths was used as a means of preventing and treating consumption.

From the 1850s onward various devices were created to exercise the lungs by inhaling and or exhaling against resistance. Some of the more common methods were described by Tissier in his 1903 book "Pneumotherapy: Including Aertherapy and Inhalation methods."

According to Tissier, all of these devices or techniques provide similar results, and none has an advantage over the others.  The ultimate goal being to exercise the lungs on a daily basis with the goal of, over time, increasing respiratory capacity.  

Some examples are:

1  Valsalva Meneuver:  This is a technique we still recommend today when a patient's heart goes into certain funky rhythms to try to get it back to normal. Back then it was used as a therapy to exercise the lungs.

Basically, the patient takes a full inspiration, and then exhales through a closed glottis with all your respiratory muscles, making a full, and forceful expiratory effort. When I explain this to my patients, I basically say to the patient to exhale as though you were trying to take a crap. It's a funky way of explaining it, but it works.

The effect of this technique (and all the devices described here) is to exercise all the respiratory muscles, and it also increased intra-thoracic pressure. By increasing intrathoracic pressure, the circulation is also slowed because the vessels are squeezed and this slows circulation.

Figure 40 -- Howe's Breathing Tube

The increased pressure also recruits alveoli and portions of the lung not used regularly, and this works to improve breathing.  This creates more room for air exchange in the lungs.  We now know this causes a form of PEEP that increases oxygenation.  A similar effect is created when a newborn is grunting or crying.  Thus, Tissier suggests crying exercises respiratory muscles, and parents who don't let their children cry risk having their child's lung muscles not developing properly, and this predisposes them, so he believed, to tuberculosis of the lungs.

Figure 41-- Resistance Spirometer

2.  Ramadge Tube:  The tube was recommended for patients suffering from tuberculosis. Due to his invention he is often described as the Father of Aerotherapy.

Tissier describes the Ramadge Tubes this way: "Ramadge had his patients breathe the emanations from heated tar through long narrow tubes, the diameters varying with the ages of the patients, and attributed all the benefits derived from the inhalation to this respiratory exercise of the lungs. The length of the tube serves the double purpose of protecting the patient's face from the heat of the inhaling apparatus, and of retarding the free egress of air from the lungs, which is an essential feature of a perfect inhaler." I describe the Ramadge Tube in more detail in this post.

Figure 42-- Spirometer used for resistance Exercises

3.  Dobell's Residual Air Pump:  I described this device in my last post. A patient placed the mask on his face and exhaled against pressure. The results are similar to the effects of the valsalva maneuver. However, I think the next device more resembles our modern devices, and appears to be much simpler.

4.  Cohen's Resistance Valves:  Pressure results from "Little cylinders containing ebonite valves controlled by spiral springs (Fig. 38). The tension of the spring is regulated by turning the cap of the cylinder, and a scale on the outside indicates indicates the pressure used. This device allows for resistance against both inspiration and expiration.

5.  Cohen's Simplified Resistance Valve:  It's similar to Cohen's Resistance Valve. It's less expensive, but it's also less accurate. Along with causing resistance, the "inhalant chamber (A) contains a sponge or tuft of absorbent cotton, which may be saturated with some medicinal substance." (See figure 39)

6.  Howe's Breathing Tube:  It's similar to a Ramadge Tube, which is why the tubes are sometimes referred to as either Howe's or Ramadge's Tube. Since it provided pressure and also allowed for the inhalation of medicine, both the Ramadge and Howe tubes are sometimes referred to as inhalers. (see figure 40)

7.  Resistance Spirometer:  They are used the same way as the Ramadge and Howe Tubes, or any of the above devices and, again, offer no advantage over any of the above. However, the device can be used day to day and allows the patient to monitor his progress by writing down daily the values indicated on the spirometer. There were many similar devices, two of which are indicated in figures 41 and 42.

Further Reading

1. The first PEP Therapy, Incentive Spirometer

References:  

1. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
2. Minnesota State Medical Society, "Transaction of the Minnesota State Medical Society," 1886, St. Paul, H. M. Smyth Printing Co.

1835: Ramadge's inhaling tube for consumption and asthma

Figure 1 -- Ramadge Iinhaling Pipe (1, page 93)

Respiratory therapists are well aware of insentive spirometers (IS) and positive end expiratory (PEP) therapy. You might think these are modern inventnions. You would be wrong.

Incentive Spirometers are small, hand held devices that that encourage patients who are on pain medicine, or who had recent abdominal or chest surgery, to take deep breath and cough to facilitate movement of secretions, thereby preventing or treating atelectasis and pneumonia. The incentive spirometer was invented in 1970 by R.H. Bartlett and quickly became an inexpensive mode of bedside therapy.

PEP therapy involves having the patient blow through a resistor that applies resistance, or positive pressure (usually 10-20 cwp), during expiration. The pressure acts as a splint to keep otherwise collapsible terminal airways and alveoli open. This facilitates the movement of secretions that would otherwise be trapped due to airway closure. It was invented in Denmark during the 1970s and was became popular in Scandanavia, Denmark and Canada before making its way to the United States. (5, page 1001)

So both IS and PEP therapy were invented during the 1970s and are forms of chest physiotherapy, or chest exercise through manual movement. However, the general concept was conceived of back in 1810 by a doctor by the name of Francis Ramadge.

He was a student of Rene Laennec, the inventor of the stethoscope.  The two men worked together in order to find a means of preventing people from developing consumption, the most common respiratory disease at that time.

Laennec suggested a natural cure for consumption was the formation of cicatrizations, or scar tissue, following the softening of the tubercles.  This scar tissue, he suspected, acted as a natural barrier against the disease. He suspected most people living with the disease had such scar tissue.

Ramadge, on the other hand, believed that since consumption resulted in a small, contracted and frail rib cage, anything causing the opposite effect prevented consumption. Various other physicians agreed with Ramadge. (1, pages 91- 93)  (3, page 8-9, 37)

Two such diseases suspected as acting as natural barriers against the disease, Ramadge suspected, were catarrh (colds) and asthma. He said:

For instance, let us begin with catarrh. Here tumefaction (swelling) of the mucous membrane preventing the free egress of the air, imprisons it in the air-cells, and produces a quasi emphysematous state of the lungs, expanding their entire volume to a certain degree, and pushing outwards in every direction the walls of the chest. Asthma also acts in a similar way. (3, page 8)

They believed if patients took care of their asthma this would act as a barrier to consumption. Ramadge said that this was one of the "ulterior good" effects of having asthma. It was "a lesser evil being substituted for a greater." (6, page 37)(1, pages 91- 93) (3, page 9, 37)

Ramadge also believed that any medical condition that impeded free expiration tended to "mitigate and arrest the disease."  Such conditions included: enlarged tonsils, tumors pointing towards the pharynx, polyps in the nasal passages, aneurysms of the aorta, diseases of the heart, obstruction of the liver, hysteria and pregnancy.  (3, page 8)

It was based on these theories that he invented what was called "an inhaling pipe," which would later be referred to as the Ramadge Inhaling Pipe.  He believed that by inhaling and exhaling through the pipe the patient would develop an expanded chest. In this way, regular use of the pipe had "palliatve and prophylactic, as well as a curative, intentions." (1, page 93) (3, page 10, 59)

It was a pipe with hot tar stuffed into it that you inhaled for therapeutic means. The tar, and the narrow diameter of the tube, provided resistance to inspiration and expiration, and this was supposed to provide "gymnastics" or "exercise" for the consumptive patients.

The Ramadge Inhaling Pipe wasn't exactly PEP therapy, but the principle was similar.  He said:

The value of the tube in catarrh, which it supersedes as a curative agent, must not be overlooked. By due exercise and expansion of the bronchial ramifications, it contributes to allay, or indispose to, irritability of the lining membrane, and I have often heard patients state that after its use in the morning they have been better, and more freely able to bring up the accumulated phlegm. (3, page 59)

The inhaling pipe wasn't an IS, although it worked similarly to encourage deep breathing and coughing.

Ramadge said:

The lungs may simply and safely be kept in daily exercise, and expansion to the full amount may be effected by atmospheric inhalation, through the respiratory apparatus. (3, page 15)

Dr. Samuel Sheldon Fitch, in his 1847 book "Six lectures on the uses of the lungs," described the tube.  He said: (1, page 91-93)

This tube he at first made about four and a half feet long, with an opening through its whole length, provided with a mouth-piece to go between the lips, and the patient sucked in, or inhaled the air as long as he could, and then through the same tube, blew it out again. By this process, the chest would rapidly enlarge. Dr. Eamadge also made an inhaling tube a little like a whistle, with a valve in it so constructed that the air would go into the mouth and lungs through a large free passage, and on returning, the air would be forced to go outmof the mouth and lungs through a much smaller opening. The effect of which is, to allow the lungs to fill rapidly and without exhaustion of strength, and on leaving the lungs, it is all passed through an opening not much larger than a knitting- needle, by which the air was slowly forced out of the lungs, and by this pressure the lungs were greatly expanded, and the air every where opened the chest in the largest manner. (1, page 93)

Fitch said the tubes were made of wood or ivory, although he recommended they be made of gold, platina or silver so that they last long, and the patient can take the tube wherever he goes and can use it often to keep his lungs expanded.  (1,2)

Ramadge said he'd prefer his patients use the inhaling tube...

...but, in the absence of the inhaler, I have no hesitation in saying, on the Principle of choosing the minor of two evils, that exposure to the exciting causes of catarrh, under prudent restrictions, is an alternative that may be judiciously adopted in consumption. (3, page 15)

Surely there were other remedies for consumption, such as leeches, tonics, sedatives and relocation, but...

...The use of the inhaling tube I consider to be essential in the treatment of phthisis; indeed, all other treatment is comparatively secondary and ancillary. (3, page 10)

He said it worked even as a last ditch effort to save the life of a consmptive in the dire states of the disease.  He said:

It may be thrown out as a sheet-anchor, even at the eleventh hour. A clergyman's daughter, who had been despaired of, in phthisis, by several medical men, was induced, as a dernier ressort,to employ the inhaling apparatus for two or three months, during which period a decided retrogression of all her bad symptoms was established. Considering herself well, she left it off and died. It is not improbable that, had she gone on till her disease had been more completely brought. (3, page 59) 

While recommended for consumptive patients, he said his inhaling device also worked well for asthmatics.  He said:

In asthma the windpipe is too small for the volume of the lungs, and, though it may seem contradictory, the mechanical respiration by the tube has the effect of restoring this disturbed relation to its healthy standard. The objection to it, on the score that asthma is liable to be superinduced by its use, arises from idle prejudice. Could I but present one-tenth part of the cases which have been rescued from a premature grave, chiefly by means of using this instrument, I should force irresistible conviction on the most incredulous, or at least induce them to institute a number of experiments, patiently and judiciously, so as to satisfy themselves of the truth. (2, page 10)

Not sold yet as to the efficacy of the Ramadge inhalaing pipe?  Well, how about some endorsements that might change your mind.  Ramadge said:

This mode of treatment has many advocates, both in England and abroad. Lebeau, physician to the King of the Belgians, and senior surgeon of the Military Hospital at Brussels, as also Hohnbaum, physician to the Duke of Saxe Meiningen, and a distinguished pathologist, highly approve of it. Among the American medical men might be mentioned, the names of Drs. Pitch, Newton, and Hull, of Philadelphia, and several other distinguished practitioners of the same country, together with a great many continental physicians, all of whom have adopted its use, and are its zealous supporters. (3, page 11) 

Ramadge would go on to become a well respected physician who specialized in pulmonary disease, ultimately becoming senior physician to the Infirmary for Asthma, Consumption, and other diseases of the Lungs. He claimed to have had the advantage of over 30,000 cases of consumption in all its various stages. He said:

I have no hesitation in asserting -- in contradiction to the opinion of many medical practitioners -- that this disease when properly, judiciously, and skillfully treated, is a curable as any other disease, the curability of which is not dispute. (1, page iv)

The Ramadge Tube was recommended by physicians for pulmonary gymnastics and as a prophylactic therapy for consumption until better devices were invented at the turn of the next century. (4, page 228)

Further reading:

• 1819: Laennec says consumption can be cured
• 1910: Early PEP and Incentive Spirometers

References:

1. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
2. Laennec, Rene, "On Mediate Auscultation," 1827, London, T and G Underwood.  
3. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
4. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
5. Sehlin, et al, "Physiological Responses to Positive Expiratory Pressure Breathing:A Comparison of the PEP Bottle and the PEP Mask,"  Respiratory Care, August, 2007, Vol. 52, No. 8, pages 1000-1005

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